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Provenza CG, Romanelli JR. Achalasia: Diagnosis and Management. Surg Clin North Am 2025; 105:143-158. [PMID: 39523069 DOI: 10.1016/j.suc.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
Achalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Typical symptoms of achalasia are dysphagia, retrosternal chest pain, regurgitation, and weight loss. Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.
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Affiliation(s)
- Christina G Provenza
- University of Massachusetts Chan Medical School, Baystate Medical Center, Springfield, MA, USA
| | - John Robert Romanelli
- University of Massachusetts Chan Medical School, Baystate Medical Center, Springfield, MA, USA.
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Fukushima N, Masuda T, Tsuboi K, Watanabe J, Yano F. Long-term outcomes of treatment for achalasia: Laparoscopic Heller myotomy versus POEM. Ann Gastroenterol Surg 2024; 8:750-760. [PMID: 39229567 PMCID: PMC11368501 DOI: 10.1002/ags3.12807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/27/2024] [Accepted: 04/04/2024] [Indexed: 09/05/2024] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by nonrelaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM), a less invasive treatment, is performed extensively, and the selection of the intervention method remains debatable to date. In addition to the availability of extensive studies on short-term outcomes, recent studies on the long-term outcomes of LHM and POEM have shown similar clinical success after 5 y of follow-up. However, gastroesophageal reflux disease (GERD) was more common in patients who had undergone POEM than in those who had undergone LHM. Moreover, existing studies have compared treatment outcomes in various disease states. Some studies have suggested that POEM is superior to LHM for patients with type III achalasia because POEM allows for a longer myotomy. Research on treatment for sigmoid types is currently in progress. However, the long-term results comparing LHD and POEM are insufficient, and the best treatment remains controversial. Further research is needed, and treatment options should be discussed with patients and tailored to their individual needs and pathologies.
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Affiliation(s)
- Naoko Fukushima
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Takahiro Masuda
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Kazuto Tsuboi
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Jun Watanabe
- Division of Gastroenterological, General and Transplant Surgery, Department of SurgeryJichi Medical UniversityShimotsukeTochigiJapan
| | - Fumiaki Yano
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
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Malik A, Qureshi S, Nadir A, Malik MI, Adler DG. Efficacy and safety of laparoscopic Heller's myotomy versus pneumatic dilatation for achalasia: A systematic review and meta-analysis of randomized controlled trials. Indian J Gastroenterol 2024; 43:740-747. [PMID: 38564157 DOI: 10.1007/s12664-023-01497-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/01/2023] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND OBJECTIVES: Achalasia has several treatment modalities. We aim to compare the efficacy and safety of laparoscopic Heller myotomy (LHM) with those of pneumatic dilatation (PD) in adult patients suffering from achalasia. METHODS We searched Cochrane CENTRAL, PubMed, Web of Science, SCOPUS and Embase for related clinical trials about patients suffering from achalasia. The quality appraisal and assessment of risk of bias were conducted with GRADE and Cochrane's risk of bias tool, respectively. Homogeneous and heterogeneous data was analyzed under fixed and random-effects models, respectively. RESULTS The pooled analysis of 10 studies showed that PD was associated with a higher rate of remission at three months, one year, three years and five years (RR = 1.25 [1.09, 1.42] (p = 0.001); RR = 1.13 [1.05, 1.20] (p = 0.0004); RR = 1.48 [1.19, 1.82] (p = 0.0003); RR = 1.49 [1.18, 1.89] (p = 0.001)), respectively. LHM was associated with lower number of cases suffering from adverse events, dysphagia and relapses (RR = 0.50 [0.25, 0.98] (p = 0.04); RR = 0.33 [0.16, 0.71] (p = 0.004); RR = 0.38 [0.15, 0.97] (p = 0.04)), respectively. There is no significant difference between both groups regarding the lower esophageal pressure, perforations, remission rate at two years, Eckardt score after one year and reflux. CONCLUSION PD had higher remission rates than LHM at three months, one year and three years, but not at two years or five years. More research is needed to determine whether PD has a significant advantage over LHM in terms of long-term remission rates.
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Affiliation(s)
- Adnan Malik
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | - Shahbaz Qureshi
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | - Abdul Nadir
- Division of Gastroenterology, Mountain Vista Medical Center, Mesa, AZ, USA
| | | | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy Centura Health, Porter Adventist Hospital, Denver, CO, USA.
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Mittal S, Kumar A, Gunjan D, Netam RK, Anil AK, Suhani S, Joshi M, Bhattacharjee HK, Sharma R, Parshad R. Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia. Surg Endosc 2024; 38:659-670. [PMID: 38012444 DOI: 10.1007/s00464-023-10571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.
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Affiliation(s)
- Sonali Mittal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritesh Kumar Netam
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Abhijith K Anil
- Department of Physiology, All India Institute of Medical Sciences, New Delhi, India
| | - Suhani Suhani
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Joshi
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanga K Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Sharma
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 419, 4th Floor, Surgery Block, New Delhi, 110029, India.
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Nita AF, Chanpong A, Nikaki K, Rybak A, Thapar N, Borrelli O. Recent advances in the treatment of gastrointestinal motility disorders in children. Expert Rev Gastroenterol Hepatol 2023; 17:1285-1300. [PMID: 38096022 DOI: 10.1080/17474124.2023.2295495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Pediatric gastrointestinal motility disorders represent some of the most challenging clinical conditions with largely undefined pathogenetic pathways and therefore limited therapeutic options. Herein, we provide an overview of the recent advances in treatment options for these disorders and their clinical impact. AREAS COVERED PubMed and Medline databases were searched for relevant articles related to the treatment of achalasia, esophageal atresia, gastroparesis, PIPO and constipation published between 2017 and 2022. In this article, we review and summarize recent advances in management of gastrointestinal motility disorders in children with a particular focus on emerging therapies as well as novel diagnostic modalities that help guide their application or develop new, more targeted treatments. EXPERT OPINION Gastrointestinal motility disorders represent one of the most challenging conundrums in pediatric age and despite significant advances in investigative tools, the palette of treatment options remain limited. Overall, while pharmacological options have failed to bring a curative solution, recent advances in minimal invasive therapeutic and diagnostic techniques have emerged as potential keys to symptom and quality of life improvement, such as ENDOFLIP, POEM, cine-MRI, fecal microbiota transplantation.
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Affiliation(s)
- Andreia Florina Nita
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Atchariya Chanpong
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Division of Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - Kornilia Nikaki
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Anna Rybak
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Osvaldo Borrelli
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
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Abstract
BACKGROUND Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. OBJECTIVES To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. SEARCH METHODS We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. SELECTION CRITERIA We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. DATA COLLECTION AND ANALYSIS Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. MAIN RESULTS We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. AUTHORS' CONCLUSIONS When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.
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Affiliation(s)
- Sumit Midya
- Department of General Surgery, Frimley Park Hospital, Frimley, UK
| | - Debasish Ghosh
- Department of General Surgery, Royal Berkshire Hospital, Reading, UK
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Elyasinia F, Sadeghian E, Gapeleh R, Eslamian R, Najjari K, Soroush A. The Role of Fundoplication after Laparoscopic Heller Myotomy in Reducing Postoperative Symptoms in Patients with Achalasia: A Controlled Clinical Trial. Middle East J Dig Dis 2022; 14:437-442. [PMID: 37547508 PMCID: PMC10404100 DOI: 10.34172/mejdd.2022.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/18/2022] [Indexed: 08/08/2023] Open
Abstract
Background: Laparoscopic Heller myotomy (LHM) is considered the standard surgical approach in patients newly diagnosed with achalasia worldwide. However, proceeding to fundoplication after LHM remains controversial due to the observed postoperative symptoms, including dysphagia and regurgitation. This study was conducted to compare the postoperatively experienced regurgitation and dysphagia between those undergoing LHM with fundoplication and those with mere LHM. Methods: This four-year controlled clinical trial was performed on adult patients with esophageal type two achalasia, referring to the Shariati Hospital, who gave their written informed consent to enroll. The diagnosis of achalasia was confirmed using manometric assessments. The control group underwent LHM with fundoplication, while the cases received LHM without fundoplication. The validated Achalasia Patients Questionnaire was used for assessing the experienced symptoms pre- and postoperatively. Also, esophagography was used to investigate the alterations of the symptoms pre- and postoperatively. Results: A total of 48 patients were evaluated. 23 were assigned to the case group, while 25 were considered the controls (male to female ratio: 25 to 23). The mean age of the patients was 36.94 years, and the average disease duration was 6.22 years. Cases and controls were matched demographically. There was no statistically significant difference between the cases and controls regarding postoperative active or passive regurgitation or dysphagia to either solids or fluids. Also, the mean score of total clinical symptoms after the surgery was not significantly different between cases and controls. Lastly, esophagography revealed significant improvement regarding all the symptoms postoperatively (P=0.001); however, no statistically significant difference existed in this regard between cases and controls. Conclusion: Our results indicate no significant difference regarding the postoperative achalasia-related symptoms, namely regurgitation and dysphagia, between those patients undergoing LHM with and without fundoplication. However, further studies are required to thoroughly investigate the effects of various fundoplication techniques in relation to all achalasia-related symptoms to confirm these results.
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Affiliation(s)
- Fezzeh Elyasinia
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Sadeghian
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Gapeleh
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Eslamian
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Khosrow Najjari
- Department of Surgery, School of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Soroush
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Darwish MB, Logarajah SI, Nagatomo K, Jackson T, Benzie AL, McLaren PJ, Cho E, Osman H, Jeyarajah DR. To Wrap or Not to Wrap After Heller Myotomy. JSLS 2021; 25:JSLS.2021.00054. [PMID: 34803368 PMCID: PMC8580166 DOI: 10.4293/jsls.2021.00054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and Objectives: The primary aim of this study is to assess the necessity of fundoplication for reflux in patients undergoing Heller myotomy for achalasia. The secondary aim is to assess the safety of the robotic approach to Heller myotomy. Methods: This is a single institution, retrospective analysis of 61 patients who underwent robotic Heller myotomy with or without fundoplication over a 4-year period (January 1, 2015 – December 31, 2019). Symptoms were evaluated using pre-operative and postoperative Eckardt scores at < 2 weeks (short-term) and 4 – 55 months (long-term) postoperatively. Incidence of gastroesophageal reflux and use of antacids postoperatively were assessed. Long-term patient satisfaction and quality of life (QOL) were assessed with a phone survey. Finally, the perioperative safety profile of robotic Heller myotomy was evaluated. Results: The long-term average Eckardt score in patients undergoing Heller myotomy without fundoplication was notably lower than in patients with a fundoplication (0.72 vs 2.44). Gastroesophageal reflux rates were lower in patient without a fundoplication (16.0% vs 33.3%). Additionally, dysphagia rates were lower in patients without a fundoplication (32.0% vs 44.4%). Only 34.8% (8/25) of patients without fundoplication continued use of antacids in the long-term. There were no mortalities and a 4.2% complication rate with two delayed leaks. Conclusion: Robotic Heller myotomy without fundoplication is safe and effective for achalasia. The rate of reflux symptoms and overall Eckardt scores were low postoperatively. Great patient satisfaction and QOL were observed in the long term. Our results suggest that fundoplication is unnecessary when performing Heller myotomy.
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Affiliation(s)
- Muhammad B Darwish
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | | | - Kei Nagatomo
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - Terence Jackson
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | | | | | - Edward Cho
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - Houssam Osman
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
| | - D Rohan Jeyarajah
- Department of Surgery, Methodist Richardson Medical Center, Richardson, TX
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Csendes A, Orellana O, Figueroa M, Lanzarini E, Panza B. Long-term (17 years) subjective and objective evaluation of the durability of laparoscopic Heller esophagomyotomy in patients with achalasia of the esophagus (90% of follow-up): a real challenge to POEM. Surg Endosc 2021; 36:282-291. [PMID: 33471177 DOI: 10.1007/s00464-020-08273-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Laparoscopic Heller Myotomy (LHM) with partial anterior or posterior fundoplication is the standard surgical procedure for treating achalasia patients. The results reported are mainly based on symptomatic evaluations and have less than 5 years of follow-up and none more than ten. OBJECTIVE To determine the late results of LHM, performing endoscopic, histologic, manometric, and functional studies in addition to clinical evaluations. MATERIALS AND METHODS Eighty-nine consecutive patients were included in a prospective study from 1993 to 2008. Inclusion criteria corresponded to achalasia patients with Types I to III (radiological evaluation). Exclusion criteria included patients with grade IV, patients with previous procedures (surgical or endoscopic), or giant hiatal hernia. They were submitted to a radiological evaluation, over two endoscopic procedures with biopsy samples, manometric assessments, and 24-h pH monitoring late after surgery. RESULTS There was no operative mortality nor postoperative complications. The average hospital stay was two days. Nine patients (10.1%) were lost from follow-up. The mean late follow-up was 17 years (10-26). Visick I and II (success) corresponded to 78.7% of patients and grades III-IV (failure) to 21.3%, mainly due to gastroesophageal reflux disease (GERD). Manometric evaluations showed a significant and permanent decrease in lower esophageal sphincter pressure (LESP). 24-h pH monitoring was normal among Visick I patients and showed pathologic acid reflux in patients with GERD. Two patients (2.5%) developed Barrett's esophagus. Squamous-cell carcinoma (SCC) appeared in three patients (3.7%). CONCLUSION LHM controlled symptoms in 79% of achalasia patients very late (17 years) after surgery. This was corroborated by endoscopic, manometric, and functional studies. GERD symptoms developed in 18.7% and SCC in 3.7% in previously asymptomatic patients. Endoscopic surveillance at regular intervals is recommended for all patients who have had surgery. These very long-term results are a real challenge to POEM endoscopic treatment. Unique Identifying Registration Number 3743.
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Affiliation(s)
- Attila Csendes
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile.
| | - Omar Orellana
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| | - Manuel Figueroa
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| | - Enrique Lanzarini
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
| | - Benjamin Panza
- Department of Surgery, University of Chile Clinical Hospital, Santos Dumont # 999, Santiago, Chile
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Santes O, Coss-Adame E, Valdovinos MA, Furuzawa-Carballeda J, Rodríguez-Garcés A, Peralta-Figueroa J, Narvaez-Chavez S, Olvera-Prado H, Clemente-Gutiérrez U, Torres-Villalobos G. Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients? Surg Endosc 2020; 35:4991-5000. [DOI: 10.1007/s00464-020-07978-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
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Doubova M, Gowing S, Robaidi H, Gilbert S, Maziak DE, Shamji FM, Sundaresan RS, Villeneuve PJ, Seely AJE. Long-term Symptom Control After Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia. Ann Thorac Surg 2020; 111:1717-1723. [PMID: 32891651 DOI: 10.1016/j.athoracsur.2020.06.095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 06/03/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two thirds of the esophagus. A favored treatment is laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with more than 90% immediate beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of postoperative symptom control over time is less understood. METHODS Between 2004 and 2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation, and quality of life. Symptom ratings were done preoperatively, 4 weeks postoperatively, 6 months postoperatively, and yearly after the operation. RESULTS As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD, and quality of life after the operation (P < .001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation, and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3 to 5 years postoperatively (P = .001 and P = .04, respectively), with associated increased antireflux medication use. After initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years postoperatively, and no patient required reoperation. Patients reported preserved improved quality of life to 11 years after the operation (P = .001). CONCLUSIONS These results demonstrate the durability of LHMDor in the definitive management of achalasia, offering consistent symptomatic relief and significant improvement in quality of life over the decade after surgery, despite some increase in GERD symptoms and antireflux medication use.
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Affiliation(s)
- Maria Doubova
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Gowing
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Hassan Robaidi
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sebastien Gilbert
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Donna E Maziak
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Farid M Shamji
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - R Sudhir Sundaresan
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick James Villeneuve
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew J E Seely
- Division of Thoracic Surgery, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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12
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Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
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Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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13
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Inaba CS, Wright AS. Laparoscopic Heller Myotomy and Toupet Fundoplication for Achalasia. J Laparoendosc Adv Surg Tech A 2020; 30:630-634. [PMID: 32392447 DOI: 10.1089/lap.2020.0158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Achalasia manifests as failure of relaxation of the lower esophageal sphincter resulting in dysphagia. Although there are several medical and endoscopic treatment options, laparoscopic Heller myotomy has excellent short- and long-term outcomes. This article describes in detail our surgical approach to this operation. Key steps include extensive esophageal mobilization, division of the short gastric vessels, mobilization of the anterior vagus nerve, an extended gastric myotomy (3 cm as opposed to the conventional 1-2 cm gastric myotomy), a minimum 6 cm esophageal myotomy through circular and longitudinal muscle layers, and a Toupet partial fundoplication. We routinely use intraoperative endoscopy both to check for inadvertent full-thickness injury and to assess completeness of the myotomy and the geometry of the anti-reflux wrap.
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Affiliation(s)
- Colette S Inaba
- Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Andrew S Wright
- Department of Surgery, Center for Esophageal and Gastric Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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14
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Jung HK, Hong SJ, Lee OY, Pandolfino J, Park H, Miwa H, Ghoshal UC, Mahadeva S, Oshima T, Chen M, Chua ASB, Cho YK, Lee TH, Min YW, Park CH, Kwon JG, Park MI, Jung K, Park JK, Jung KW, Lim HC, Jung DH, Kim DH, Lim CH, Moon HS, Park JH, Choi SC, Suzuki H, Patcharatrakul T, Wu JCY, Lee KJ, Tanaka S, Siah KTH, Park KS, Kim SE. 2019 Seoul Consensus on Esophageal Achalasia Guidelines. J Neurogastroenterol Motil 2020; 26:180-203. [PMID: 32235027 PMCID: PMC7176504 DOI: 10.5056/jnm20014] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/08/2020] [Indexed: 12/13/2022] Open
Abstract
Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.
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Affiliation(s)
- Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - John Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hyojin Park
- Division of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjiv Mahadeva
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tadayuki Oshima
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | | | - Yu Kyung Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Tae Hee Lee
- Department of Internal Medicine, College of Medicine, Soonchunhyang University Hospital, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joong Goo Kwon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Gangwon-do, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Chul Lim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Hyun Lim
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jung Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Korea
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Tanisa Patcharatrakul
- Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Justin C Y Wu
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Kwang Jae Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Gyeonggi-do, Korea
| | - Shinwa Tanaka
- Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
| | - Kewin T H Siah
- Division of Gastroenterology and Hepatology, National University Health System, Singapore City, Singapore
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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15
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Park CH, Jung DH, Kim DH, Lim CH, Moon HS, Park JH, Jung HK, Hong SJ, Choi SC, Lee OY. Comparative efficacy of per-oral endoscopic myotomy and Heller myotomy in patients with achalasia: a meta-analysis. Gastrointest Endosc 2019; 90:546-558.e3. [PMID: 31443929 DOI: 10.1016/j.gie.2019.05.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 05/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although both per-oral endoscopic myotomy (POEM) and Heller myotomy (HM) have been used for the treatment of achalasia, the comparative efficacy of POEM and HM has yet to be fully evaluated. METHODS We searched all relevant studies published up to September 2018 examining the comparative efficacy between POEM and HM. Study quality was assessed using the Newcastle-Ottawa scale. Meta-analyses for Eckardt scores, perioperative outcomes, and reflux-related outcomes were performed based on a random-effects model. RESULTS Fifteen studies with a total of 1213 patients were evaluated. The follow-up duration ranged from 2 to 46.2 months and from 2 to 54.2 months in the POEM and HM groups, respectively. Postoperative Eckardt scores were lower (better) in the POEM group than in the HM group (pooled standardized mean difference [SMD], -0.58; 95% confidence interval [CI], -1.03 to -0.13). Length of myotomy was greater in the POEM group than in the HM group (pooled SMD, 0.63; 95% CI, 0.42-0.84). There was no difference in reflux symptoms and pathologic reflux on pH monitoring between the groups (pooled risk ratio [RR], 1.03; 95% CI, 0.61-1.73; and pooled RR, 1.22; 95% CI, 0.67-2.25, respectively). Erosive esophagitis on endoscopy tended to be less common in the HM group (pooled RR, 1.88; 95% CI, 0.98-3.62). CONCLUSION Although long-term follow-up data are insufficient, the short-term efficacy of POEM was superior to that of HM. Erosive esophagitis tended to be more common in the POEM group; however, there was no difference in reflux symptoms and pathologic reflux on pH monitoring between the groups.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chul-Hyun Lim
- Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jung Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Su Jin Hong
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Suck Chei Choi
- Department of Internal Medicine and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea
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16
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Midya S, Ghosh D, Mahmalat MW. Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sumit Midya
- Royal Berkshire Hospital; Department of General Surgery; Reading UK RG1 5AN
| | - Debasish Ghosh
- Royal Berkshire Hospital; Department of General Surgery; Reading UK RG1 5AN
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the efficacy, morbidity and side-effects of innovative management strategies for achalasia that include high-resolution manometry (HRM), pneumatic dilatation, laparoscopic Heller's myotomy (LHM), injection of botulinum toxin into the lower esophageal sphincter and peroral endoscopic myotomy (POEM). RECENT FINDINGS HRM has enabled identification of achalasia subtypes that have important prognostic implications. Pneumatic dilatation is a commonly-used and cost-effective method of treating achalasia but has shown poor longevity of symptom relief compared with other modalities and carries a risk of esophageal perforation. LHM is often the preferred, most effective treatment modality, however new studies may show that outcomes are equivalent or even inferior to POEM. Botulinum toxin injection of the lower esophageal sphincter has a waning and short duration of efficacy and is used primarily for patients unsuitable for more definitive invasive procedures. POEM is considered the most effective treatment for type III achalasia but carries a high risk of iatrogenic gastroesophageal reflux disease that might predispose to the development of Barrett's esophagus. SUMMARY HRM and POEM are two major innovations in the management of achalasia developed over the past decade. There are now three major management options for patients with achalasia, namely pneumatic dilatation, LHM and POEM. Treatment selection should be tailored to the patient's individual esophageal physiology, physical fitness and dominant symptoms.
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18
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Di Corpo M, Farrell TM, Patti MG. Laparoscopic Heller Myotomy: A Fundoplication Is Necessary to Control Gastroesophageal Reflux. J Laparoendosc Adv Surg Tech A 2019; 29:721-725. [PMID: 31009312 DOI: 10.1089/lap.2019.0155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Achalasia is a rare esophageal motility disorder that causes progressive dysphagia and regurgitation. The aim of treatment for achalasia is to provide symptom relief by reducing esophageal outflow resistance by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity. Methods: A review of the literature concerning laparoscopic treatment of esophageal achalasia. Results: Surgical myotomy with partial fundoplication is very effective in relieving symptoms, and is able to strike a balance between relief of symptoms and control of abnormal reflux. Conclusions: Since reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma, the addition of a partial fundoplication is very important. The choice of partial fundoplication is based on surgeons' preference and expertise.
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Affiliation(s)
- Marco Di Corpo
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Timothy M Farrell
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.,2 Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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19
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Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis. Ann Surg 2019; 267:451-460. [PMID: 28549006 DOI: 10.1097/sla.0000000000002311] [Citation(s) in RCA: 251] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. BACKGROUND Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials. METHODS A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes. RESULTS Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04). CONCLUSIONS Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.
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20
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Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study. Dig Dis Sci 2018; 63:2395-2404. [PMID: 29796913 DOI: 10.1007/s10620-018-5130-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/18/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM. METHODS A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL. RESULTS Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups. CONCLUSION AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time. CLINICAL REGISTRATION NUMBER CTRI: REF/2014/06/007146.
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Repici A, Fuccio L, Maselli R, Mazza F, Correale L, Mandolesi D, Bellisario C, Sethi A, Khashab MA, Rösch T, Hassan C. GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87:934-943.e18. [PMID: 29102729 DOI: 10.1016/j.gie.2017.10.022] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 10/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Per-oral endoscopic myotomy (POEM) represents a less invasive alternative to conventional laparoscopic Heller's myotomy (LHM) for patients with achalasia. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim of our study was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM. METHODS A literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastroesophageal reflux symptoms and endoscopic monitoring and pH monitoring findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of random or fixed-effects models, according to the level of heterogeneity between studies. RESULTS After we applied the selection criteria, 17 and 28 studies, including 1542 and 2581 participants who underwent POEM and LHM, respectively, were included. The pooled rate of postprocedural symptoms was 19.0% (95% confidence interval [CI], 15.7%-22.8%) after POEM and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. The pooled rate estimate of abnormal acid exposure at pH monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. The rate of esophagitis after POEM was 29.4% (95% CI, 18.5%-43.3%) after POEM and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was explained partly by the POEM approach and study population. CONCLUSION The incidence of reflux disease appears to be significantly more frequent after POEM than after LHM with fundoplication. Monitoring pH and ensuring appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.
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Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | - Fabrizio Mazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy
| | | | - Daniele Mandolesi
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cristina Bellisario
- Department of Cancer Screening, Centre for Epidemiology and Prevention in Oncology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas Rösch
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
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22
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Rebecchi F, Allaix ME, Schlottmann F, Patti MG, Morino M. Laparoscopic Heller Myotomy and Fundoplication: What Is the Evidence? Am Surg 2018. [DOI: 10.1177/000313481808400418] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
There is no agreement about the best type of fundoplication to add in patients undergoing laparoscopic Heller myotomy (LHM) for achalasia to reduce the risk of postoperative gastroesophageal reflux. This article reviews the current evidence about the outcomes in achalasia patients undergoing LHM with a partial anterior, a partial posterior, or a total fundoplication. We performed a review of the literature in PubMed/Medline electronic databases, which was evaluated according to the GRADE system. The results of the published randomized controlled trials show with a high level of evidence that the addition of a fundoplication reduces the risk of postoperative abnormal reflux, without impairing the food emptying of the esophagus. LHM with partial fundoplication is considered in most centers worldwide the standard of care for the treatment of patients with achalasia. The current evidence fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trial, the decision of performing an anterior or a posterior wrap is based on the surgeon's experience and preference. The addition of a partial fundoplication to LHM leads to a significantly lower rate of postoperative pathological reflux without impairing the esophageal emptying.
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Affiliation(s)
- Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Torino, Italy and
| | - Marco E. Allaix
- Department of Surgical Sciences, University of Torino, Torino, Italy and
| | - Francisco Schlottmann
- Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marco G. Patti
- Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Torino, Italy and
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23
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Schlottmann F, Herbella F, Allaix ME, Patti MG. Modern management of esophageal achalasia: From pathophysiology to treatment. Curr Probl Surg 2018; 55:10-37. [DOI: 10.1067/j.cpsurg.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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24
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Tancredi A, Cuttitta A, Scaramuzzi R, Scaramuzzi G, Taurchini M. Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication. Eurasian J Med 2017; 49:1-6. [PMID: 28416923 DOI: 10.5152/eurasianjmed.2017.16151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aim of the present study is to show the predictive value of the preoperative resting pressure of the lower esophageal sphincter (LES) correlated with the type of fundoplication (Nissen or Dor) after Heller myotomy in our series. MATERIALS AND METHODS From January 1998 to June 2010, 88 patients affected by esophageal achalasia underwent surgery at our unit. However, our study focused on a sample of 36 patients, because many data were lost or was never recorded. Among these, 14 patients underwent laparoscopic Heller myotomy plus Nissen fundoplication (group N), whereas 22 patients underwent laparoscopic Heller myotomy plus Dor fundoplication (group D). Clinical evaluation was performed using a modified DeMeester symptom scoring system consisting of the assessment of three symptoms: dysphagia, regurgitation, and heartburn. To each symptom was assigned a score from 0 to 3, depending on its severity, and the reduction in the severity of each symptom after surgery was assessed. RESULTS The surgical treatment is considered to be effective (p<0.0001). The preoperative resting pressures of LES were compared by Student's t-test, and it was found that patients who reported a greater improvement in the dysphagia symptom had a preoperative average pressure of LES that was significantly higher than that in other patients in both group N (p=0.03) and group D (p=0.01; p=0.003; p=0.001). The Dor treatment was shown to be more effective than the Nissen treatment (p<0.0001). CONCLUSION The preoperative resting pressure of LES is a predictive factor of surgical success both before Dor fundoplication and before Nissen fundoplication, but its predictive power is influenced by the chosen type of fundoplication.
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Affiliation(s)
- Antonio Tancredi
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy.,Department of Emergency, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Antonello Cuttitta
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Roberto Scaramuzzi
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy.,Department of Emergency, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy.,Department of Thoracic Surgery, Second University of Naples, Naples, Italy
| | - Gerardo Scaramuzzi
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
| | - Marco Taurchini
- Department of General Surgery and Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, Foggia, Italy
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Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, Dousset B, Elizalde JI, Fumagalli U, Gaudric M, Merla A, Smout AJ, Tack J, Zaninotto G, Busch OR, Boeckxstaens GE. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 2016; 65:732-9. [PMID: 26614104 DOI: 10.1136/gutjnl-2015-310602] [Citation(s) in RCA: 241] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/01/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Achalasia is a chronic motility disorder of the oesophagus for which laparoscopic Heller myotomy (LHM) and endoscopic pneumodilation (PD) are the most commonly used treatments. However, prospective data comparing their long-term efficacy is lacking. DESIGN 201 newly diagnosed patients with achalasia were randomly assigned to PD (n=96) or LHM (n=105). Before randomisation, symptoms were assessed using the Eckardt score, functional test were performed and quality of life was assessed. The primary outcome was therapeutic success (presence of Eckardt score ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for re-treatment, lower oesophageal sphincter pressure, oesophageal emptying and the rate of complications. RESULTS In the full analysis set, there was no significant difference in success rate between the two treatments with 84% and 82% success after 5 years for LHM and PD, respectively (p=0.92, log-rank test). Similar results were obtained in the per-protocol analysis (5-year success rates: 82% for LHM vs. 91% for PD, p=0.08, log-rank test). After 5 years, no differences in secondary outcome parameter were observed. Redilation was performed in 24 (25%) of PD patients. Five oesophageal perforations occurred during PD (5%) while 12 mucosal tears (11%) occurred during LHM. CONCLUSIONS After at least 5 years of follow-up, PD and LHM have a comparable success rate with no differences in oesophageal function and emptying. However, 25% of PD patients require redilation during follow-up. Based on these data, we conclude that either treatment can be proposed as initial treatment for achalasia. TRIAL REGISTRATION NUMBERS Netherlands trial register (NTR37) and Current Controlled Trials registry (ISRCTN56304564).
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Affiliation(s)
- An Moonen
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Vito Annese
- Head of Gastroenterology, Department of Emergency, AOU Careggi, Florence, Italy
| | - Ann Belmans
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, KU, Leuven, Belgium
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Bertrand Dousset
- Department of GI and Endocrine Surgery, Hôpital Cochin, Paris, France
| | - J I Elizalde
- Department of Gastroenterology, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Uberto Fumagalli
- Upper GI Surgery, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | | | - Antonio Merla
- Division of Gastroenterology, IRCCS, "Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Andre J Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan Tack
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
| | - Giovanni Zaninotto
- Department of Academic Surgery, St Mary's Hospital, Imperial College, London, UK
| | - Olivier R Busch
- Gastrointestinal Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Guy E Boeckxstaens
- Department of Gastroenterology, Catholic University of Leuven, Leuven, Belgium
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Abstract
A laparoscopic Heller myotomy with partial fundoplication is considered today in most centers in the United States and abroad the treatment of choice for patients with esophageal achalasia. Even though the operation has initially a very high success rate, dysphagia eventually recurs in some patients. In these cases, it is important to perform a careful work-up to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. The best results are obtained by a team approach, in Centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this disease.
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The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on peroral endoscopic myotomy. Gastrointest Endosc 2015; 81:1087-100.e1. [PMID: 25799295 DOI: 10.1016/j.gie.2014.12.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/08/2014] [Indexed: 12/13/2022]
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Cuttitta A, Tancredi A, Andriulli A, De Santo E, Fontana A, Pellegrini F, Scaramuzzi R, Scaramuzzi G. Fundoplication after heller myotomy: a retrospective comparison between nissen and dor. Eurasian J Med 2015; 43:133-40. [PMID: 25610181 DOI: 10.5152/eajm.2011.31] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 10/24/2011] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia. MATERIALS AND METHODS From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system. RESULTS Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively. CONCLUSION Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up.
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Affiliation(s)
- Antonello Cuttitta
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Antonio Tancredi
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy ; PhD School in Internal Medicine and Medical Therapy, Department of Internal Medicine and Medical Therapy, University of Pavia, Piazzale Golgi, Pavia, PV, Italy
| | - Angelo Andriulli
- Unit of Gastroenterology, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Ermelinda De Santo
- Unit of Gastroenterology, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Andrea Fontana
- Unit of Biostatistics, IRCCS "Casa Sollievo della Soff erenza" Hospital-Viale Cappuccini, San Giovanni Rotondo, FG, Italy
| | - Fabio Pellegrini
- Unit of Biostatistics, IRCCS "Casa Sollievo della Soff erenza" Hospital-Viale Cappuccini, San Giovanni Rotondo, FG, Italy ; Laboratory of Clinical Epidemiology of Diabetes and Chronic Diseases, Consorzio Mario Negri Sud-Via Nazionale, Santa Maria Imbaro, CH, Italy
| | - Roberto Scaramuzzi
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy ; Graduate School of Medicine, Catholic University of the Sacred Heart - Largo Francesco Vito, Rome, Italy
| | - Gerardo Scaramuzzi
- Unit of General Surgery 2 and Thoracic Surgery, IRCCS "Casa Sollievo della Soff erenza" Hospital, Viale Cappuccini, San Giovanni Rotondo, FG, Italy
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Omura N, Yano F, Tsuboi K, Hoshino M, Yamamoto SR, Akimoto S, Ishibashi Y, Kashiwagi H, Yanaga K. Short-term surgical outcomes of reduced port surgery for esophageal achalasia. Surg Today 2015; 45:1139-43. [PMID: 25563589 DOI: 10.1007/s00595-014-1109-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 12/09/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE To clarify the feasibility and utility of reduced port surgery (RPS) for achalasia. METHODS Between September 2005 and June 2013, 359 patients with esophageal achalasia, excluding cases of reoperation, underwent laparoscopic Heller myotomy and Dor fundoplication (LHD) according to our clinical pathway. Three-hundred and twenty-seven patients underwent LHD with five incisions (conventional approach), while the other 32 patients underwent RPS, including eight via SILS. The clinical data were collected in a prospective fashion and retrospectively reviewed. We selected 24 patients matched for gender, age and morphologic type with patients in the RPS group from among the 327 patients (C group). The surgical outcomes were compared between the C and RPS groups. RESULTS There were no significant differences between the two groups in the duration of symptoms, dysphagia score, chest pain score, shape of the distal esophagus and esophageal clearance. The operative time was significantly longer in the RPS group than in the C group (p < 0.001). There were no significant differences between the two groups in the length of postoperative hospital stay or rates of bleeding, mucosal injury of the esophagus and/or stomach and postoperative complications. The symptom scores significantly improved after surgery in both groups (p < 0.001). Furthermore, there were no significant differences between the C group and RPS group in terms of the postoperative symptom scores or satisfaction scores after surgery. CONCLUSIONS The surgical outcomes of RPS for achalasia are comparable to those obtained with the conventional method.
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Affiliation(s)
- Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan,
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30
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Rossetti G, Fei L, del Genio G, Maffettone V, Brusciano L, Tolone S, Cimmino M, Moccia F, Terrone A, Romano G, Guerriero L, del Genio A. Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature. Scand J Surg 2014; 102:129-35. [PMID: 23820690 DOI: 10.1177/1457496913482242] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors' experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen-Rossetti fundoplication. MATERIAL AND METHODS From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45-74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen-Rossetti fundoplication. RESULTS The mean operative time was 135 min (range = 105-190 min). Mean hospital stay was 14.2 days (range = 7-25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6-192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%). CONCLUSIONS Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.
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Affiliation(s)
- G Rossetti
- I Division of General and Gastrointestinal Surgery, Second University of Naples, Naples, Italy
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31
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Symptomatic outcome following laparoscopic Heller’s cardiomyotomy with Dor fundoplication versus laparoscopic Heller’s cardiomyotomy with angle of His accentuation: results of a randomized controlled trial. Surg Endosc 2014; 29:2344-51. [PMID: 25427411 DOI: 10.1007/s00464-014-3958-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/03/2014] [Indexed: 02/03/2023]
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32
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Rossetti G, Limongelli P, Cimmino M, Napoletano D, Bondanese MC, Romano G, Pratilas M, Guerriero L, Orlando F, Conzo G, Amato B, Docimo G, Tolone S, Brusciano L, Docimo L, Fei L. Outcome of medical and surgical therapy of GERD: predictive role of quality of life scores and instrumental evaluation. Int J Surg 2014; 12 Suppl 1:S112-6. [PMID: 24946311 DOI: 10.1016/j.ijsu.2014.05.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Aim of this study is to determine whether quality of life (QoL) assessment in association with instrumental evaluation can help to identify factors predictive of outcome both in surgically and medically treated GERD patients. METHODS Between January 2005 and June 2010, 301 patients affected with GERD were included in the study. QoL was evaluated by means of GERD-HRQL and SF-36 questionnaires administered before treatment, at 6 months, at 1 year follow-up and at the end of the study. The multivariate analysis was used to detect if variables such as sex, age, heartburn, acid regurgitation, dysphagia, presence of esophagitis, percentage of total time at pH < 4, symptom index score (SI), the SF-36 and HRQL scores before treatment, at 6 months and 1 year could affect the QoL questionnaires scores at the end of the study. RESULTS One hundred forty-seven patients were included in the surgical group and 154 in the medical group. No differences with regard to gender, age, mean SF-36 and HRQL scores before treatment were documented. At the end of the study, quality of life was significantly improved for SF-36 and HRQL scores, either for surgical or medical group. The multivariate analysis showed no factors individually affected the SF-36 and the HRQL scores, but symptom index score (SI) and QoL questionnaires scores at 6 months and 1 year follow-up. CONCLUSIONS The combined use of pHmetry with evaluation of SI and QoL questionnaires can predict the outcome of GERD patients managed either by medical or surgical therapy.
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Affiliation(s)
- Gianluca Rossetti
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Paolo Limongelli
- Division of General and Bariatric Surgery, School of Medicine, Second University of Naples, Italy.
| | - Marco Cimmino
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Domenico Napoletano
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Maria Chiara Bondanese
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Giovanni Romano
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Manousos Pratilas
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Ludovica Guerriero
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Francesco Orlando
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Giovanni Conzo
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, School of Medicine, University of Naples Federico II, Italy.
| | - Giovanni Docimo
- Division of General and Bariatric Surgery, School of Medicine, Second University of Naples, Italy.
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, School of Medicine, Second University of Naples, Italy.
| | - Luigi Brusciano
- Division of General and Bariatric Surgery, School of Medicine, Second University of Naples, Italy.
| | - Ludovico Docimo
- Division of General and Bariatric Surgery, School of Medicine, Second University of Naples, Italy.
| | - Landino Fei
- Department of Anaesthesiological, Surgical and Emergency Sciences, Division of Digestive Surgery, School of Medicine, Second University of Naples, Via Pansini, 5, 80131 Naples, Italy.
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Are contrast swallows necessary immediately postlaparoscopic Heller cardiomyotomy? Surg Laparosc Endosc Percutan Tech 2014; 24:e167-9. [PMID: 24710247 DOI: 10.1097/sle.0b013e3182901660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Laparoscopic cardiomyotomy is an effective treatment for achalasia. Intraoperative leak tests are carried out to exclude mucosal perforations, additionally some surgeon perform postoperative contrast swallows. The aim of the study was to identify whether postoperative contrast swallows were necessary in all patients who undergo laparoscopic cardiomyotomy. All patients who underwent a laparoscopic cardiomyotomy at a single center between 2004 and 2011 were identified. Median age was 55 (18 to 79), median body mass index 26 (17 to 37), and median length of stay was 1 day (1 to 4). A total of 54% of patients had previous pneumatic dilatations. One intraoperative mucosal perforation was identified and repaired. No leaks were seen on the postoperative swallow; however, 1 patient was readmitted with a contained leak, 8 days after surgery. Postoperative contrast swallow did not have any clinical impact. We suggest that they are only indicated if there is a clinical concern and that laparoscopic cardiomyotomy can be safely carried out as a day case procedure.
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Long-term outcome after laparoscopic myotomy for achalasia. J Thorac Cardiovasc Surg 2014; 147:730-6; Discussion 736-7. [DOI: 10.1016/j.jtcvs.2013.09.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 09/10/2013] [Accepted: 09/30/2013] [Indexed: 11/18/2022]
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Abstract
Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders (TARGID), University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium.
| | - Giovanni Zaninotto
- Department of Surgical and Gastroenterological Sciences, University of Padova, UOC General Surgery, Sts Giovanni e Paolo Hospital, Venice, Italy
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, Joy McCann Culverhouse Center for Esophageal and Swallowing Disorders, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Fei L, Rossetti G, Moccia F, Marra T, Guadagno P, Docimo L, Cimmino M, Napolitano V, Docimo G, Napoletano D, Guerriero L, Pascotto B. Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up. BMC Surg 2013; 13 Suppl 2:S13. [PMID: 24267613 PMCID: PMC3851262 DOI: 10.1186/1471-2482-13-s2-s13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background In this prospective non randomized observational cohort study we have
evaluated the influence of age on outcome of laparoscopic total
fundoplication for GERD. Methods Six hundred and twenty consecutive patients underwent total laparoscopic
fundoplication for GERD. Five hundred and twenty-four patients were younger
than 65 years (YG), and 96 patients were 65 years or older (EG). The
following parameters were considered in the preoperative and postoperative
evaluation: presence, duration, and severity of GERD symptoms, presence of a
hiatal hernia, manometric and 24 hour pH-monitoring data, duration of
operation, incidence of complications and length of hospital stay. Results Elderly patients more often had atypical symptoms of GERD and at manometric
evaluation had a higher rate of impaired esophageal peristalsis in
comparison with younger patients. The duration of the operation was similar
between the two groups. The incidence of intraoperative and postoperative
complications was low and the difference was not statistically significant
between the two groups. An excellent outcome was observed in 93.0% of young
patients and in 88.9% of elderly patients (p = NS). Conclusions Laparoscopic antireflux surgery is a safe and effective treatment for GERD
even in elderly patients, warranting low morbidity and mortality rates and a
significant improvement of symptoms comparable to younger patients.
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Bello B, Herbella FA, Allaix ME, Patti MG. Impact of minimally invasive surgery on the treatment of benign esophageal disorders. World J Gastroenterol 2012; 18:6764-70. [PMID: 23239914 PMCID: PMC3520165 DOI: 10.3748/wjg.v18.i46.6764] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 05/26/2012] [Accepted: 07/18/2012] [Indexed: 02/06/2023] Open
Abstract
Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.
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Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817-25. [PMID: 23032978 PMCID: PMC3808165 DOI: 10.1038/ajg.2012.332] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature. METHODS We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. RESULTS At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02). CONCLUSIONS Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.
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Weber CE, Davis CS, Kramer HJ, Gibbs JT, Robles L, Fisichella PM. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2012; 22:289-96. [PMID: 22874676 DOI: 10.1097/sle.0b013e31825a2478] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.
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Affiliation(s)
- Cynthia E Weber
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA
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Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm. Surg Laparosc Endosc Percutan Tech 2012; 22:83-7. [PMID: 22487617 DOI: 10.1097/sle.0b013e318243368f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
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Revisional surgery after heller myotomy for treatment of achalasia: a comparative analysis focusing on operative approach. Indian J Surg 2012; 74:309-13. [PMID: 23904720 DOI: 10.1007/s12262-011-0402-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 12/22/2011] [Indexed: 10/14/2022] Open
Abstract
Surgical myotomy is the gold standard in therapy for achalasia, but treatment failures occur and require revisional surgery. A MEDLINE search of peer-reviewed articles published in English from 1970 to December 2008 was performed using the following terms: esophageal achalasia, Heller myotomy, and revisional surgery. Thirty-three articles satisfied our inclusion criteria. A total of 12,727 patients, with mean age of 43.3 years (males 46% and females 50%), underwent Heller myotomy (open 94.8% and laparoscopic 5.2%). Revisional surgery was performed in 6.19%. Procedures performed included revision of the original myotomy or creation of a new myotomy with or without an antireflux procedure or esophagectomy. Reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (3.04%). Systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of reoperation with a low mortality rate.
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Impact of total fundoplication on esophageal transit: analysis by combined multichannel intraluminal impedance and manometry. J Clin Gastroenterol 2012; 46:e1-5. [PMID: 22157223 DOI: 10.1097/mcg.0b013e31822f3735] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total). METHODS In this study, 25 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-EM and combined 24-hour pH and multichannel intraluminal impedance (MII-pH) before and after the surgical procedure. All patients completed preoperative and postoperative symptom questionnaires. The following were calculated for liquid and viscous deglutition lower esophageal sphincter pressure and relaxation, distal esophageal amplitude, the number of complete esophageal bolus transits and the mean total bolus transit time. The acid and nonacid GER episodes were calculated by MII-pH with the patient in both upright and recumbent positions. RESULTS The postoperative MII-EM showed an increased lower esophageal sphincter pressure (P < 0.05), whereas lower esophageal sphincter relaxation and distal esophageal amplitude did not change after surgery (P = NS). Complete esophageal bolus transits and bolus transit time did not change for liquid swallows (P = NS), but was more rapid for viscous after surgery (P < 0.05). Twenty-four hour pH monitoring confirmed the postoperative reduction of both acid and nonacid reflux (P < 0.05). CONCLUSIONS Laparoscopic Nissen-Rossetti is effective in controlling both acid and nonacid GER without impairment of esophageal function. Appropriate preoperative investigation, meticulous patient selection and correct surgical technique are extremely important in securing good results.
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Parise P, Rosati R, Savarino E, Locatelli A, Ceolin M, Dua KS, Tatum RP, Braghetto I, Gyawali CP, Hejazi RA, McCallum RW, Sarosiek I, Bonavina L, Wassenaar EB, Pellegrini CA, Jacobson BC, Canon CL, Badaloni A, del Genio G. Barrett's esophagus: surgical treatments. Ann N Y Acad Sci 2011; 1232:175-95. [PMID: 21950813 DOI: 10.1111/j.1749-6632.2011.06051.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.
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Affiliation(s)
- Paolo Parise
- Department of General Surgery IV, Regional Referal Center for Esophageal Pathology, Pisa, Italy
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SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
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Bello B, Herbella FA, Patti MG. Evolution of the minimally invasive treatment of esophageal achalasia. World J Surg 2011; 35:1442-6. [PMID: 21400015 DOI: 10.1007/s00268-011-1027-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.
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Affiliation(s)
- Brian Bello
- Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, MC 5031, Room G-201, Chicago, IL 60637, USA
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Bello B, Herbella FA, Patti MG. Evolution of the minimally invasive treatment of esophageal achalasia. World J Surg 2011. [PMID: 21400015 DOI: 10.1007/s00268-011-1027-5.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
Thanks to the advent of laparoscopic techniques, the last decade and a half have witnessed a radical change in the treatment of esophageal achalasia. Because of the high success rate of the laparoscopic Heller myotomy, surgery has now become in many centers the first modality of treatment for achalasia. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection.
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Affiliation(s)
- Brian Bello
- Department of Surgery, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, MC 5031, Room G-201, Chicago, IL 60637, USA
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Martino ND, Brillantino A, Monaco L, Marano L, Schettino M, Porfidia R, Izzo G, Cosenza A. Laparoscopic calibrated total vs partial fundoplication following Heller myotomy for oesophageal achalasia. World J Gastroenterol 2011; 17:3431-40. [PMID: 21876635 PMCID: PMC3160569 DOI: 10.3748/wjg.v17.i29.3431] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 12/26/2010] [Accepted: 01/02/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the mid-term outcomes of laparoscopic calibrated Nissen-Rossetti fundoplication with Dor fundoplication performed after Heller myotomy for oesophageal achalasia.
METHODS: Fifty-six patients (26 men, 30 women; mean age 42.8 ± 14.7 years) presenting for minimally invasive surgery for oesophageal achalasia, were enrolled. All patients underwent laparoscopic Heller myotomy followed by a 180° anterior partial fundoplication in 30 cases (group 1) and calibrated Nissen-Rossetti fundoplication in 26 (group 2). Intraoperative endoscopy and manometry were used to calibrate the myotomy and fundoplication. A 6-mo follow-up period with symptomatic evaluation and barium swallow was undertaken. One and two years after surgery, the patients underwent symptom questionnaires, endoscopy, oesophageal manometry and 24 h oesophago-gastric pH monitoring.
RESULTS: At the 2-year follow-up, no significant difference in the median symptom score was observed between the 2 groups (P = 0.66; Mann-Whitney U-test). The median percentage time with oesophageal pH < 4 was significantly higher in the Dor group compared to the Nissen-Rossetti group (2; range 0.8-10 vs 0.35; range 0-2) (P < 0.0001; Mann-Whitney U-test).
CONCLUSION: Laparoscopic Dor and calibrated Nissen-Rossetti fundoplication achieved similar results in the resolution of dysphagia. Nissen-Rossetti fundoplication seems to be more effective in suppressing oesophageal acid exposure.
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Gockel I, Gith A, Drescher D, Jungmann F, Eckhard L, Lang H. Minimally invasive surgery for achalasia in patients >40 years: more favorable than anticipated. Langenbecks Arch Surg 2011; 397:69-74. [PMID: 21818656 DOI: 10.1007/s00423-011-0832-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 07/26/2011] [Indexed: 01/11/2023]
Abstract
PURPOSE The efficacy of Heller myotomy in patients >40 years-a significant predictor suggesting a favorable response to pneumatic dilation-has been questioned. The aim of our study was to evaluate the results obtained in patients aged <40 and >40 years undergoing minimally invasive surgery (MIS) for achalasia. METHODS In January 2008, we established the MIS technique for achalasia in our clinic. In the following period from January 2008 to March 2011, 74 patients underwent primary laparoscopic myotomy for achalasia. The procedure was accomplished with an anterior 180° semifundoplication according to Dor in all patients. The Eckardt score and the Gastrointestinal Quality of Life Index (GQLI) served as outcome measures. RESULTS The median age of patients was 45.5 years (range, 18-85 years) with a median duration of preoperative achalasia symptoms of 57 months (range, 2-468 months). There were no conversions to open surgery and-except for one patient with a sterile pleural effusion-no postoperative complications. At a median follow-up of 12 months, the preoperative Eckardt score of 7.0 (range, 3-12) was found to be significantly decreased to a median of 2 (range, 0-6; P < 0.001). With regard to patients <40 and >40 years, the postoperative Eckardt score obtained in the older patient population was not significantly lower (P = 0.074). There was no statistically significant difference between the two groups with respect to the postoperative GQLI (P = 0.860). Neither gender nor preoperative Botox injection or pneumatic dilation inserted a significant influence on the postoperative clinical outcome (P > 0.05). CONCLUSIONS Laparoscopic Heller myotomy for achalasia is associated with a high success rate as the primary therapeutic option and after failure of endoscopic therapy. It can be performed safely and with favorable outcomes also in patients >40 years. However, the long-term durability of the procedure remains to be established.
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Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Langenbeckstr. 1, 55131, Mainz, Germany.
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Rawlings A, Soper NJ, Oelschlager B, Swanstrom L, Matthews BD, Pellegrini C, Pierce RA, Pryor A, Martin V, Frisella MM, Cassera M, Brunt LM. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 2011; 26:18-26. [PMID: 21789646 DOI: 10.1007/s00464-011-1822-y] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 06/22/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy. METHODS A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test. RESULTS Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups). CONCLUSION Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.
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Affiliation(s)
- Arthur Rawlings
- Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave., Box 8109, St. Louis, MO 63110, USA
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Kashiwagi H, Omura N. Surgical treatment for achalasia: when should it be performed, and for which patients? Gen Thorac Cardiovasc Surg 2011; 59:389-98. [PMID: 21674305 DOI: 10.1007/s11748-010-0765-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 12/13/2010] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare motor disorder of the esophagus, characterized by the absence of peristalsis and impaired swallow-induced relaxation. In the past decade, evidence has been accumulated suggesting that achalasia may be an immune-mediated inflammatory disorder. With the advent of minimally invasive surgery, laparoscopic Heller myotomy (LHM) has slowly shifted the treatment of achalasia toward the greater use of surgical therapy. The goal of both surgical and nonsurgical treatment is to eliminate the outflow obstruction afforded by a nonrelaxing sphincter, relieving dysphagia and maintaining a barrier against gastroesophageal reflux (GER). Endoscopic botulinum toxin injection (EBTI) is safe, easy to perform, inexpensive, and effective in aged patients, and it is especially effective when the lower esophageal pressure is hypertonic. This therapeutic option is reserved for patients too ill to undergo any surgical procedure. Pneumatic dilation (PD) has been shown to be an effective and inexpensive treatment with few adverse effects. The long-term success rate of PD seems to drop progressively over time. Heller myotomy (HM) has shown the best clinical efficacy in achalasia as a first-line treatment. Multiple endoscopic treatments are associated with poorer outcomes after HM. EBTI also makes LHM more difficult and results in a worse surgical outcome. The inferior symptomatic outcomes after thoracoscopic HM may be caused by the difficulty in extending an adequate myotomy onto the stomach from the chest and the inability to create a fundoplication. LHM with Dor's fundoplication (LHM + Dor) is effective and is safer procedure for avoiding GER, dysphagia, mucosal perforation, and a pseudodiverticulum. LHM + Dor is also effective in the presence of sigmoid achalasia, but the clinical result is not as good as nonsigmoid achalasia. A few patients need esophagectomy for surgical failure of HM. However, considering the risk of esophagectomy, LHM + Dor is the first treatment option for patients with achalasia regardless of the degree of esophageal dilatation. This procedure is therefore considered to be an effective and safe treatment for patients of any age or with any condition.
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Affiliation(s)
- Hideyuki Kashiwagi
- Department of Surgery, Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-ku, Tokyo 105-8461, Japan.
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